Background Chronic kidney disease (CKD) and hyperuricemia often coexist, and both conditions are increasing in prevalence in the United States. However, their shared role in cardiovascular risk remains highly debated. Study Design Cross-sectional and longitudinal. Setting & Participants Participants in the National Health and Nutrition Examination Survey (NHANES) from 1988 to 2002 (n = 10,956); data were linked to mortality data from the National Death Index through December 31st, 2006. Predictors Serum uric acid concentration, categorized as the sex-specific lowest (<25th), middle (25th–<75th), and highest (≥75th) percentiles; and kidney function assessed by estimated glomerular filtration rate (eGFR) based on the CKD-EPI (CKD Epidemiology Collaboration) creatinine–cystatin C equation, and urinary albumin-creatinine ratio (ACR) Outcomes Cardiovascular death and all-cause mortality. Results Uric acid levels were correlated with eGFRcr-cys (r = −0.29; p<0.001), and were only slightly correlated with ACR (r = 0.04; p<0.001). There were 2,203 deaths up until December 31st, 2006, of which 981 were due to cardiovascular causes. Overall, there was a U-shaped association between uric acid levels and cardiovascular mortality in both women and men, although the lowest risk of cardiovascular mortality occurred at a lower level of uric acid for women compared with men. There was an association between the highest quartile of uric acid and cardiovascular mortality even after adjustment for potential confounders (HR, 1.48; 95% CI, 1.13–1.96), although this association was attenuated after adjustment for ACR and eGFRcr-cys (HR, 1.25; 95% CI, 0.89–1.75). The pattern of association between uric acid levels and all-cause mortality was similar. Limitations GFR not measured; mediating events were not observed. Conclusions High uric acid is associated with cardiovascular and all-cause mortality, although this relationship was no longer statistically significant after accounting for kidney function.

There has been great interest recently in better understanding how an episode of acute kidney injury (AKI) affects risk of development or acceleration of chronic kidney disease. This area of epidemiology research presents several methodological challenges that have not been sufficiently discussed in the literature. These are related to the current consensus definitions of AKI; the determination of 'baseline' renal function before the AKI episode; and the possibility that observed associations between AKI and future adverse events are confounded by differences in the severity of baseline chronic kidney disease. In this study, we discuss several potential solutions to these problems. Concerted efforts to address these methodological issues will propel research in this field to a higher level.

Background The diagnosis of chronic kidney disease (CKD) is based on laboratory results easily extracted from electronic health records; therefore, CKD identification and management is an ideal area for targeted electronic decision support efforts. Early CKD management frequently occurs in primary care settings where primary care providers (PCPs) may not implement all the best practices to prevent CKD-related complications. Few previous studies have employed randomized trials to assess a CKD electronic clinical decision support system (eCDSS) that provided recommendations to PCPs tailored to each patient based on laboratory results. Objective The aim of this study was to report the trial design and implementation experience of a CKD eCDSS in primary care. Methods This was a 3-arm pragmatic cluster-randomized trial at an academic general internal medicine practice. Eligible patients had 2 previous estimated-glomerular-filtration-rates by serum creatinine (eGFR Cr ) <60 mL/min/1.73m 2 at least 90 days apart. Randomization occurred at the PCP level. For patients of PCPs in either of the 2 intervention arms, the research team ordered triple-marker testing (serum creatinine, serum cystatin-c, and urine albumin-creatinine-ratio) at the beginning of the study period, to be completed when acquiring labs for regular clinical care. The eCDSS launched for PCPs and patients in the intervention arms during a regular PCP visit subsequent to completing the triple-marker testing. The eCDSS delivered individualized guidance on cardiovascular risk-reduction, potassium and proteinuria management, and patient education. Patients in the eCDSS+ arm also received a pharmacist phone call to reinforce CKD-related education. The primary clinical outcome is blood pressure change from baseline at 6 months after the end of the trial, and the main secondary outcome is provider awareness of CKD diagnosis. We also collected process, patient-centered, and implementation outcomes. Results A multidisciplinary team (primary care internist, nephrologists, pharmacist, and informaticist) designed the eCDSS to integrate into the current clinical workflow. All 81 PCPs contacted agreed to participate and were randomized. Of 995 patients initially eligible by eGFR Cr , 413 were excluded per protocol and 58 opted out or withdrew, resulting in 524 patient participants (188 usual care; 165 eCDSS; and 171 eCDSS+). During the 12-month intervention period, 53.0% (178/336) of intervention patient participants completed triple-marker labs. Among these, 138/178 (77.5%) had a PCP appointment after the triple-marker labs resulted; the eCDSS was opened for 73.9% (102/138), with orders or education signed for 81.4% (83/102). Conclusions Successful integration of an eCDSS into primary care workflows and high eCDSS utilization rates at eligible visits suggest ...

Most adults with chronic kidney disease (CKD) in the United States are cared for by primary care providers (PCPs). We evaluated the feasibility and preliminary effectiveness of an electronic clinical decision support system (eCDSS) within the electronic health record with or without pharmacist follow-up to improve the management of CKD in primary care. Study Design: Pragmatic cluster-randomized trial. Setting & Participants: 524 adults with confirmed creatinine-based estimated glomerular filtration rates of 30 to 59 mL/min/1.73 m 2 cared for by 80 PCPs at the University of California San Francisco. Electronic health record data were used for patient identification, intervention deployment, and outcomes ascertainment. Interventions: Each PCP's eligible patients were randomly assigned as a group into 1 of 3 treatment arms: (1) usual care; (2) eCDSS: testing of creatinine, cystatin C, and urinary albumincreatinine ratio with individually tailored guidance for PCPs on blood pressure, potassium, and proteinuria management, cardiovascular risk reduction, and patient education; or (3) eCDSS plus pharmacist counseling (eCDSS-PLUS). Outcomes: The primary clinical outcome was change in blood pressure over 12 months. Secondary outcomes were PCP awareness of CKD and use of angiotensin-converting enzyme inhibitor/ angiotensin receptor blocker and statin therapy. Results: All 80 eligible PCPs participated. Mean patient age was 70 years, 47% were nonwhite, and mean estimated glomerular filtration rate was 56 ± 0.6 mL/min/1.73 m 2. Among patients receiving eCDSS with or without pharmacist counseling (n = 336), 178 (53%) completed laboratory measurements and 138 (41%) had laboratory measurements followed by a PCP visit with eCDSS deployment. eCDSS was opened by the PCP for 102 (74%) patients, with at least 1 suggested order signed for 83 of these 102 (81%). Changes in systolic blood pressure were −2.1 ± 1.5 mm Hg with usual care, −2.8 ± 1.8 mm Hg with eCDSS, and −1.1 ± 1.1 with eCDSS-PLUS (P = 0.7). PCP awareness of CKD was 16% with usual care, 26% with eCDSS, and 32% for eCDSS-PLUS (P = 0.09). In as-treated analyses, PCP awareness of CKD was significantly greater with eCDSS and eCDSS-PLUS (73% and 69%) versus usual care (47%; P = 0.002). Limitations: Recruitment of smaller than intended sample size and limited uptake of the testing component of the intervention. Editorial, p. 613 Complete author and article information provided before references.